MANAGED CARE UPDATE

O.D.s and the State of the Unions

by Randolph Brooks, O.D. 

Physicians' unions have been around for at least the last 25 years, but recent events are focusing new attention on the idea of doctors carrying union cards and bargaining as groups.

Medical doctors face many of the same difficulties as optometrists when dealing with managed-care plans. Many feel powerless to negotiate reimbursement, and they feel as if they've lost control over patient care.

That led a group of Philadelphia O.D.s to form the nation's first optometric union in late 1997. Aaron Chasan, president of the Pennsylvania Optometric Guild, says MCOs were affecting optometrists' ability to manage their practices and deliver effective eye care to patients. This problem seemed especially apparent in southeastern Pennsylvania, where two major HMOs dominated the market.

Optometry has faced an additional challenge: discrimination by managed care plans that refuse to admit O.D.s to their panels.

Whether you're for or against unionization, optometry has become a bigger player in health care. So, we must watch as events unfold and participate in the debate.

At the AMA's annual convention in June, its House of Delegates voted to establish a national physicians' union. This union would only represent employed doctors—about 17 percent of the nation's physicians, according to American Medical News—in negotiations with HMOs and hospitals. That's because federal anti-trust laws prohibit self-employed physicians from collective bargaining.

Doctors have argued that lower reimbursements by MCOs represent significant control over their practices and essentially make them employees of the plans. So far, the National Labor Relations Board has rejected this argument. In May, the NLRB ruled that some 650 New Jersey doctors are independent contractors, not employees, of an HMO. So, a union could not collectively bargain with the HMO on their behalf (see News Review, "Two States, Two Approaches to Fee Negotiation," June 1999).

That could change if Congress passes the Quality Health-Care Coalition Act of 1999, or H.R. 1304. The bill, introduced by Reps. Thomas Campbell (R-Calif.) and John Conyers (D-Mich.), would allow individual physicians to collectively bargain with managed-care organizations. The AMA's House of Delegates directed the association to continue its support for the bill, although there will likely be significant opposition from the managed-care community.

Farther south, Texas recently passed the nation's first law that gives physicians some negotiating power. The bill is not a union bill, but it does allow a limited number of doctors in a given area to bargain collectively with health plans. However, they first need the permission of the state attorney general to do so.

What does all this mean for optometry? Dr. Chasan believes O.D.s can benefit from unionization. The Pennsylvania Optometric Guild is actively supporting the Campbell bill. This bill, he says, has the purpose of leveling the playing field by allowing room for negotiation with managed-care plans. He does not believe the bill discriminates against optometrists.

Dr. Chasan believes support of bills similar to that of Texas in other state legislatures is important. He says an optometric guild would support similar legislation, provided it doesn't discriminate against optometrists.

Organized optometry hasn't taken an official stance on unionization. Some O.D.s have told me that optometric unions would make them feel like blue-collar workers, and they worry about the potential for harmful boycotts or strikes. They also feel that informational demonstrations, such as the one that took place outside of Independence Blue Cross' headquarters in Philadelphia in late 1997, bear a strong relationship to picketing, and many O.D.s find this troublesome for professionals.

However, Dr. Chasan says this does not have to be the case, especially given the rapid escalation of unionization in the medical fields.

The AOA is not supporting the Campbell bill in its present form. The association's concern is that the bill might enable M.D.s to circumvent antitrust laws (see News Review, "Will Doctors Get to Bargain with Insurers?" May 1999). My concern: The Campbell bill, as currently written, does not define "health-care professionals." So, we need to know whether this bill would cover optometrists before we decide to support it.

There are no easy answers to concerns over unions, collective bargaining, patient-care decisions and discrimination against optometrists by managed-care plans. As O.D.s in such major urban markets as Philadelphia continue to feel competitive pressure, you can expect continued focus and debate on optometric unions into the first quarter of the 21st century.

Send questions to Dr. Brooks c/o Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089; or e-mail them to reviewofoptometry@jobson.com.